Form Mch 213g - School Entrance Health Form Page 3

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Student’s Name:

Date of Birth: |____ |_ ___|___ _|

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Section II

Conditional Enrollment and Exemptions

Complete the medical exemption or conditional enrollment section as appropriate to include signature and date.

MEDICAL EXEMPTION: As specified in the Code of Virginia § 22.1-271.2, C (ii), I certify that administration of the vaccine(s) designated below would be

detrimental to this student’s health. The vaccine(s) is (are) specifically contraindicated because (please specify):

__________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________.

DTP/DTaP/Tdap:[

]; DT/Td:[

]; OPV/IPV:[

]; Hib:[

]; Pneum:[

]; Measles:[

]; Rubella:[

]; Mumps:[

]; HBV:[

]; Varicella:[

]

This contraindication is permanent: [

], or temporary [

] and expected to preclude immunizations until: Date (Mo., Day, Yr.): |___|___|___|.

Signature of Medical Provider or Health Department Official:

Date (Mo., Day, Yr.):|___|___|___|

RELIGIOUS EXEMPTION: The Code of Virginia allows a child an exemption from receiving immunizations required for school attendance if the student or the

student’s parent/guardian submits an affidavit to the school’s admitting official stating that the administration of immunizing agents conflicts with the student’s religious

tenets or practices. Any student entering school must submit this affidavit on a CERTIFICATE OF RELIGIOUS EXEMPTION (Form CRE-1), which may be obtained at

any local health department, school division superintendent’s office or local department of social services. Ref. Code of Virginia § 22.1-271.2, C (i).

CONDITIONAL ENROLLMENT: As specified in the Code of Virginia § 22.1-271.2, B, I certify that this child has received at least one dose of each of the vaccines

required by the State Board of Health for attending school and that this child has a plan for the completion of his/her requirements within the next 90 calendar days. Next

immunization due on __________________.

Signature of Medical Provider or Health Department Official:

Date (Mo., Day, Yr.):|___|___|___|

Section III

Requirements

For Minimum Immunization Requirements for Entry into School and

Day Care, consult the Division of Immunization web site at

Children shall be immunized in accordance with the Immunization Schedule developed and published by

the Centers for Disease Control (CDC), Advisory Committee on Immunization Practices (ACIP), the

American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP),

otherwise known as ACIP recommendations (Ref. Code of Virginia § 32.1-46(a)).

(Requirements are subject to change.)